Case study: Strengthening district health systems in Karamoja

29 May 2011

Karamoja is the poorest, most remote and least developed part of Uganda. Its population of over 1.2 million people is deprived of basic services including health and access to safe water. For decades, the people here – mostly semi-nomadic pastoralists – have suffered from violence, insecurity and lack of water for their animals. Morbidity and mortality rates are very high. Out of every 1000 live births, 174 children die before the age of five – a death rate that is 27% higher than the national average. And maternal mortality is 72.4% higher than the average figure for Uganda.

Karamoja’s health system consists of 101 facilities of different sizes and types: one regional referral hospital, four general hospitals, four health centre IVs (HC IVs), 35 HC IIIs and 57 HC IIs. Of these facilities, 22 are owned by the private not-for-profit sector, while the remaining 79 are public owned. There are hardly any private for-profit facilities in the region.

Karamoja is divided into health sub-districts. Each of these consists of a set of HCIIs, HCIIIs and a referral facility such as an HC IV or a hospital. At the community level, each village is serviced by village health teams, which constitute an HC I. A total of 2910 village health team members work in the Karamoja region. These help to implement community health interventions such as immunisation, nutrition and sanitation campaigns. They are now also being equipped for community case management of common childhood illnesses.

A number of vertical programmes are being run in Karamoja. These include:

• Prevention of mother-to-child transmission of HIV/AIDS (PMTCT)
• HIV/AIDS programmes run by various partners
• Reproductive health programmes
• Nutrition programmes run by various partners
• Expanded outreach programmes
• Neglected diseases programmes, particularly for kalazar (leishmaniasis) and filiariasis (elephantiasis)

These programmes are called vertical because they have their own work plans, management structures, funding and reporting systems – although most do tend to use the same district staff to implement their activities. Vertical programmes have a tendency to cause fragmented planning, fragmented resource mobilisation, and an overlap or even a doubling of funding for certain activities. This is a waste of resources and the increased administration activity it causes takes staff away from their broader health care tasks.

All health activities in Karamoja – public facility, private facility and vertical programmes – are coordinated by the region’s seven District Health Offices (DHOs). DHOs are headed by district health officers, who are responsible for the strategic planning and management of health in their districts. Each DHO is composed of district health team members who meet regularly. Civil and political supervision is provided by the chief administrative officer and the district executive committee represented by the Secretary for Health – an elected local politician.

The District Health Management Team (DHMT), a wider stakeholder body, is composed of the district health team members and the heads of health sub- districts, heads of health units and development partners. District health officers have a key role in ensuring that the system delivers a coherent and effective service.

Forging synergy between all these agencies requires strong leadership and governance at the district level. This, unfortunately, is often lacking in Karamoja. Governance and supervision are weak. There is a shortage of highly trained staff. There is little capacity to manage logistics and supply chains and little experience of managing health information systems, infrastructure and equipment. Planning is poor, programme implementation is weak and resources are being wasted. Strengthening capacities at district level is a must if we are to address the high levels of morbidity and mortality.

Obviously, more financial resources are required in order to tackle these health system challenges effectively – and this may not happen in the near future. But even using just the resources currently available, it is still possible to improve outcomes by improving management – in planning, in the use of resources, in the coordination of various partner inputs, in the use of information, in the management of logistics, in the deployment of staff in remote areas, in enhancing skills and improving supervision. The districts need to be strengthened in these capacities and this is the hallmark of the Cuamm intervention in Karamoja. With input from the Ugandan government and other partners, improvements are continuing to be made across Karamoja’s districts.

Strengthening the district health offices
Through its partnership with UNICEF, Cuamm is supporting district health systems in all seven districts of Karamoja. Since December 2006, Cuamm has been operating a four-phase project, responding to chronic emergency in Karamoja. The object of this has been to provide technical assistance to all DHOs. The need for such assistance was identified by a team from the Ministry of Health, UNICEF and Cuamm in August 2006 when it carried out an assessment of district health sector management. They found a number of capacity gaps.

One of the major recommendations of the assessment was to use technical advisors to support and help to build the capacity of the district health teams. Based on this, Cuamm seconded a technical advisor to each district. These were experienced public health officers, usually medical doctors, who were co-opted as members of the district health teams. They paired up and worked with task officers on the district health teams to help impart essential skills. The advisors organised and continue to be involved in supervision and mentoring within the district health teams. They also participate in technical planning committee meetings with the heads of district departments. Here, they are able to interact with the civil and political leadership of the district as well as with civil society. Their ability to advocate for continuous improvements in service delivery was mainly realised through these forums.

The key roles of the technical advisors are to:

1. Support districts to improve their capacities to plan, implement, monitor and report results
2. Support the building of a reliable health information system with demonstrable improvement in information collection, reliability, storage, retrieval, analysis, reporting and use
3. Promote Karamoja’s district forums as avenues of cross-district learning and solution sharing
4. Improve capacity to supervise, train and mentor health staff
5. Support enhanced accountability for the resources used and the results derived
6. Support cooperation with other technical heads in the district departments of education, water and sanitation, and planning

The relevance of the advisors in terms of minimising the negative effects of vertical programmes and achieving a synergy between horizontal and vertical programming lies mostly in roles 1, 2 and 5 above. In these roles, they work to prevent fragmentation and duplication, promote comprehensive planning and share information. Cuamm advisors see to it that vertical programmes do not negatively affect the delivery of the other components of the integrated Uganda National Minimum Health Care Package – the country’s primary health care package.

Advisors also provide on-the-job training for health information staff and periodic data quality assessments. They also facilitate the promotion of technology such as RapidSMS data collection, coordination and communication during disease outbreaks and disease surveillance. Every quarter, this health information is shared in the health, nutrition and HIV quarterly review meetings, which are attended by many stakeholders including NGOs and UN partners working in Karamoja. These reviews have become crucial in encouraging peer learning across districts and identifying new or persistent gaps in access. A web-based regional data centre has been set up to allow all those concerned to access health information for development.

Results
Through their active participation in the various consultative bodies, the Cuamm advisors have been effective in fostering synergies between stakeholders. This has led to clear improvements in the level of participation, more frequent and more productive meetings, and eventually, a better service for the community. These results are reflected in the performance figures of the various DHOs.

The use of primary health care resources disbursed by central government rose from 56% in 2005 (before the intervention started) to 100% in 2010. There was also an improvement in epidemic surveillance reporting. In 2005, only 49% of reports were submitted to the Ministry of Health on time. But by 2010, this had increased to 82%. This has led to measurable improvements of service delivery on the ground. Coverage of vaccinations against diphtheria, pertussis (whooping cough) and the DTP3 tetanus booster started to rise at the rate of about 3% a year in the region, while the national trend was falling at about the same rate. The outpatient utilisation rate has also been rising, and the trend in mothers opting to give birth in hospital is increasing slightly more steeply than the national rate.

As a result of a more participatory planning process, innovative approaches are beginning to emerge. For example in Kotido district, the tetanus toxoid immunisation given to young women and girls was carried out at the Sunday church service. This brought coverage of the second to fifth doses in that sub-district to 78.4% – well above the Karamoja district regional average of 36.4%, and even higher than the national target of 70%.

The DHOs in Karamoja are communication and coordination hubs. The professional demands on the district health officers and their teams are very high. The Cuamm project shows that supporting them in their capacity development helps them to improve the way they operate and give better health-service coverage to the people of Karamoja.

Authors’ conclusion
Vertical programming has always been a form of fire fighting. Although we often take pride in the quick and clean benefits demonstrated by instruments we have perfected over time, rarely do we measure the opportunity costs of vertical programmes. It will take time to convert every donor – and indeed in certain situations we may still need vertical programmes – but the message we deliver here is that vertical programmes must become increasingly diagonal in order to achieve better results.

In situations where there is deprivation and despair, it is of great value to demonstrate that confidence can be built, capacity can be developed and results can be seen. This was what the Cuamm intervention achieved – this and the ability to achieve a synergy between horizontal and vertical programming.

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About Cuamm

Doctors with Africa Cuamm is an Italian-based organisation that has been working on health issues in Africa since the 1950s. It works mainly to improve health among the poorest sections of the population. It does this through strengthening district health systems to make it easier for greater numbers of people to access primary care, by improving the quality of care available and by building the capacity of communities and local systems to recognise the health problems they are facing and find solutions to them.

Uganda is one of seven African countries where Cuamm has maintained a presence for decades. The organisation is also active in Sudan, Ethiopia, Tanzania, Mozambique, Angola and Kenya.

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